- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,236.75 / $1,236.75 / $1,236.75
| Facility | | $1,236.75 | $1,236.75 | $1,236.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.25 / $809.86 / $1,461.70
| Professional | | $670.25 | $809.86 | $1,461.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.82 / $1,391.43 / $1,735.71
| Professional | | $1,328.82 | $1,391.43 | $1,735.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.17 / $1,228.13 / $1,860.35
| Professional | | $930.17 | $1,228.13 | $1,860.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.39 / $919.11 / $1,461.70
| Professional | | $535.39 | $919.11 | $1,461.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.72 / $1,157.14 / $1,328.82
| Professional | | $1,095.72 | $1,157.14 | $1,328.82 |